Malawi – A land of opportunity and a place for new partnerships

26/09/2018
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Postdoctoral researchers Beth Mills, Gareth Williams and Elvira Bohl spent a week in Malawi at the end of August, visiting the Malawi-Liverpool Wellcome Centre and other near-by facilities in the run-up to starting a new translational research project. Beth writes about their time there:


The development of diagnostics, particularly for resource limited settings has often been hampered by inappropriate product design for the local conditions. More specifically, these design oversights include a lack of appreciation for the working environment (temperature, power supply, dust); and also the target patient population; the skill of the health worker who would use the test; the laboratory infrastructure; the cost; and also the cultural acceptability within the community. These are each considerations of paramount importance as we begin our EPSRC- funded work1 to develop ‘point-of-care frugal diagnostics’.

A mountain in Malawi

Amazing views on our walk to MLW in Blantyre, Malawi

Following an initial meeting in Edinburgh with Prof. Stephen Gordon2, director of the Malawi-Liverpool Wellcome Centre(MLW, Blantyre, Malawi)3, and thanks to funding support from College of Medicine and Veterinary Medicine (CMVM)4 and the Global Challenges Research Fund (GCRF)5 at the University of Edinburgh, myself 6, Gareth7 and Elvira8 travelled to Malawi. The purpose of our trip was to see and experience the challenges prevalent within the health care setting of this developing country in the context of our upcoming translational project.

To put into perspective how resource limited the health system is in Malawi, here are some facts and figures: The population of Malawi9 is 19 million, and the median age is just 17.5 years old. 83% of the population live in rural settings10, and 50% of the population live in poverty; the gross national income per capita is just $320 USD. Healthcare in Malawi is free at the point of use, and despite the government contributing 11% of the country’s GDP to health, this equates to just $39.2 USD per capita11 – the lowest monetary value (despite being the highest % of GDP spending) within the SADC countries12 .

Entrance gates to MLW

The entrance gate to MLW

The life expectancy within Malawi has risen sharply since 2000, from 43 years to 64 years in 2017, and the strain on the health care system was apparent as we visited the largest hospital in Malawi, the Queen Elizabeth Central hospital, situated adjacent to the MLW research centre and a primary health centre in Ndirande. We were also able to visit Malawi’s newest university, MUST (Malawi University of Science and Technology)13, where the next generation of engineers and medical scientists are being trained. Underpinning all of our experiences and conversations throughout our visit was the need for community education and engagement around health, and the work being done at MLW 14 was a shining example of this. Clearly each of these areas should work synergistically to improve health system performance and outcomes in Malawi, and an appreciation for each of them will enhance the prospects of success for our new EPSRC grant to develop point-of-care frugal diagnostics.

Our observations and thoughts from each of these visits are outlined below.

Queen Elizabeth Hospital

Our visit to Queen Elizabeth Hospital and Ndirande health centre really gave us a first-hand perspective of how heavily stretched the primary and tertiary health care sector is. For example, within the hospital (which is the largest hospital in Malawi), patients are required to bring their own bedsheets, and family members are expected to keep these washed and clean, provide food for the patient and are relied upon to administer medication at the correct time. Therefore the corridors and outside spaces are filled with the family members (and their washing) who stay for the duration of the hospital visit – losing income and removing children with no alternative childcare from school.

Queens Central Hospital, Malawi

Outside of Queens Central Hospital is full of the patients washing.

There is little in the way of facilities for these vital carers many of which have to sleep outside. For many patients, medication was simply not available because there is not enough money within the health system to import it from South Africa. The hospital only had very limited diagnostic laboratory capabilities, with more complex testing being performed next door at the MLW diagnostic labs. MLW also serves as an outstanding research facility focusing specifically on science to benefit human health, particularly within sub-Saharan Africa.

The synergistic relationship between MLW and Queen’s hospital was palpable, with clinicians and researchers firmly rooted in the local culture, sharing both research and clinical duties. We were each able to glean a great insight into the workings of Queen’s and which aspects of health are important to Malawians, and we are very grateful to everyone who took the time to speak to us.

Rose, the lead nurse in the bronchoscopy suite at MLW

Rose, the lead nurse in the bronchoscopy suite, ahead of a busy morning

It didn’t seem wholly appropriate during our visit to take photos inside the hospital, however Queen’s has been captured really well in this slideshow 15. Queen’s hospital also gave us another chance to meet up with Anstead, a bronchoscopist from Blantyre who came to visit Proteus at the start of the summer. It was a pleasure to see our friend again and to see where he works. Despite the challenging conditions there, and a lack of space, the whole bronchoscopy team that we met were really welcoming and we learnt that bronchoscopy in Malawi is not so dissimilar to in the UK. There are only two bronchoscopy departments in Malawi, so as you can imagine, Anstead is kept very busy – something that is only going to intensify as the population continues to age.

Ndirande Health Centre

The health centre visit to Ndirande was definitely a highlight moment of the week for the three of us, in particular meeting the doctor at the facility, Joseph. The health centre sees up to 400 patients a day, and Joseph is the only formally trained doctor on site – Malawi has only 1 physician per 52,632 people16, and only 1 nurse or midwife per 3,500 people. The other staff that form the backbone of the health facility are clinical officers and technical staff, or as Joseph put it, ‘bush doctors’. Each are trained for a specific area of health, and patients are triaged towards the correct stream within the centre. This healthcare setting would absolutely benefit from appropriate point-of-care diagnostic devices to provide confidence within the decision making process. Joseph and others at the Ndirande health centre identified a number of indications for which a diagnostic would be desirable to them, and fortunately for us, several overlapped with our plans.

Anstead - aka Dr Bronch

We got to meet up with Anstead again – aka Dr Bronch

They also raised the interesting considerations that the centre only has power two days a week, they have limited laboratory staff, space and budget, and experience a culture of expectation for drugs, such as antibiotics, from the patient – this is a problem the world over, however, there is evidence to suggest that a negative test result is just as satisfactory to the patient. With the acute shortage of medication within Malawi, anything to better inform the clinical officer whether the medication is required or not would be of worth. Doctor Joseph is someone that we will certainly keep in touch with in the coming months and years to liaise with over user requirements and device acceptability. My only regret from this visit is that we couldn’t spend more time there seeing the clinic in action, and that we forgot to take a photo.

MUST – the Malawi University of Science and Technology

The imposing and inspiring buildings of MUST

The imposing and inspiring buildings of MUST

MUST was a really interesting place. Situated on the outskirts of town in a very rural setting, the buildings are a stark contrast and can do nothing but inspire. The grandeur of the University echoes the ambition that Prof. Wilson Mandala, the Dean of the Academy of Clinical Sciences has for the academic outputs and for the value that this university and its students can add to Malawi.

This university was only established in 2014 but already attracts over 1300 students, with the engineering department showing significant prowess.
Indeed we were introduced to the Dean of Engineering, Prof. Davies Mweta and the engineering faculty. We had a fantastic exchange of ideas and projects that we are working on. As such a fledgling university, and with such similar interests in health care technologies, it is clear that MUST could offer a fantastic ‘win-win’ partnership for Proteus, or PhD programme Optima 17, where we could grow projects together that would be appropriate for Malawi but could draw also on resources held at the University of Edinburgh – watch this space!

Community Engagement

The final big concept that really captivated Gareth, Elvira and I was the commitment for community, school and patient engagement and education. MLW have a large team committed to this with excellent access to community groups.

Part of a large exhibition at MLW for school and community groups

This is part of a large exhibition at MLW for school and community groups

The many initiatives that Rodrick and Elvis told us about were innovative and varied, and the primary objectives, successes and concerns often mirrored those that Proteus has encountered along the way in the UK. The need for community engagement, education and involvement was also echoed by Dr Joseph at Ndirande.
It is heartening and refreshing to hear that so much focus and effort is being employed in this area in Malawi, because I think that it’s an area that is critically important, but has been largely neglected in the UK, at least until recently. Working with Rodrick and Elvis again presents itself as an extremely exciting opportunity and we are looking forward to continuing the conversation with Proteus public engagement strategist Helen.

Final thoughts:

Although our trip was short, and we only began to scratch the surface, the knowledge and understanding for the challenge that we have come away with is invaluable, and absolutely could not have been gained without a physical visit. And, perhaps most importantly, the contacts that we have made in Malawi will serve us for the years to come as we develop and disseminate our technologies. As is clear from all of the above, the three of us had an incredibly busy and varied week.

MUST engineers and Proteus team

We had some fantastic conversations with the Engineers at MUST

I think that each of these areas could warrant a trip in itself. I have spoken a lot about potential and opportunity, and I really believe that the contacts that we made in Malawi offer a real collaboration potential to work in a true partnership. Each of us is interested in the long-game to develop solutions and improvements that are sustainable and workable for resource-poor settings, such as Malawi. Malawi is often referred to as the ‘warm heart of Africa’, and this is certainly a true reflection of our time there, we were welcomed by everyone we met and there is such as positive ethos within the culture that you cannot help but feel optimistic about what can be achieved in Malawi, as long as the correct questions are asked throughout project and product development.

We really need to sincerely thank everyone that we met during our visit for their time, patience, openness and enthusiasm. In particular a huge thank you to Dr Jamie Rylance from MLW for looking after us so well, for the discussions that we had and for setting up our meetings and making the week run so smoothly.

Safari

No trip to Malawi is complete without some safari – and it was fantastic!